Meniscal tear Presentation, diagnosis and management Tim Shiraev - PDF document

Meniscal tears occur due to a shear force between the femur and the lateral is pulled out of the way of compression between femur there is a vertical or oblique tear in the posterior horn running toward • shock absorption and distributing load throughout the joint • increasing stability • providing nutrition for articular cartilage • limiting extreme flexion and extension The medial meniscus is ‘C’ shaped whereas the lateral is a shorter incomplete circle with closer spaced ‘horns’. The medial meniscus is more frequently torn, partly because of this different shape but also loaded flexed knee. These are often ‘bucket-handle tears’, in which tibia. In younger patients, this is typically a twisting force on a weight- because of its attachment to the medial collateral ligament, whereas lateral geniculate arteries supply the peripheral third of the menisci via and tibia by politeus. Superior and inferior branches of the medial and Child development Injuries Meniscal tear Presentation, diagnosis and management Tim Shiraev Suzanne E Anderson Nigel Hope Background Injury of the knee joint meniscus is one of the most Medial and lateral knee joint menisci serve to transfer load prevalent injuries in the human body. Its investigation and and absorb shock, aid joint stability and provide lubrication. treatment includes surgical techniques that are among The meniscus is the most commonly injured structure in the the most commonly performed orthopaedic procedures knee joint. Imaging techniques such as magnetic resonance worldwide. The past few decades have seen striking imaging may be warranted but are no substitute for thorough advances in our understanding of meniscal structure, clinical history and examination. function and the treatment of meniscal injuries. Attitudes Objective toward total meniscectomy have undergone reversal in This article outlines the aetiology, presentation, diagnosis the past 30 years, and even today, practices are rapidly (both clinical and radiographic) and management of these changing. Early, clinical examination, appropriate important injuries. investigation and treatment of meniscal injuries may Discussion prevent later degenerative disease and inappropriate Magnetic resonance imaging can confirm clinical concern surgical treatment that can predispose to later degenerative for meniscal tear, review intra- and extra-articular anatomical change. This article outlines the aetiology, presentation, structures and exclude alternative diagnoses. Meniscal tears diagnosis (both clinical and radiographic) and management can be assessed arthroscopically for stability and vascularity. of these important injuries. Even partial meniscectomy may lead to osteoarthritis. On the basis of the findings, treatment can be considered in terms of The menisci of the knee have several important roles: four Rs: Rest and Rehabilitate the patient (with physiotherapy), and if the patient is not improving on Review, Refer to an orthopaedic surgeon. New experimental surgical techniques seek to replace damaged tissue. These include meniscal allograft transplantation, biosynthetic scaffolds, growth factor • controlling the movements of the knee joint. 1,2 and gene therapy, or a combination of these. Keywords menisci, tibial; knee joint the perimeniscal capillary plexus. 3,4 Epidemiology, aetiology and pathophysiology the anterior horn, 5 forming a loose section which remains attached anteriorly and posteriorly. 1 In older patients, tears are generally due to 182 REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 41, NO. 4, APRIL 2012

movements (classically pivoting on the knee while walking) as a sharp femoral condyle compresses the torn meniscus. True locking is less possibly catching, clicking, difficulty on deep knee bending and locking of the knee in partial flexion. The typical meniscal pain profile comprises well localised joint-line vice-versa). Meniscal pain occurs during torsional, weight bearing knee Plain radiography is only useful to exclude differentials and computed stab lasting several seconds, often followed by a dull ache for several hours. Pain may wake the patient from sleep as the tender medial aspect of the knee strikes the other side as the patient rolls over in bed. There is no resting pain. Locking presents in two ways. Most commonly it is impossible to fully extend the knee; more accurately described as stiffness (termed ‘pseudo locking’) due either to a small effusion (requiring increased force to bend the tense joint capsule) or to pain inhibition as the common, and suggests a bucket-handle tear, with the torn fragment Meniscal tears often occur in young patients who have suffered a preventing full extension. There is a history of sudden inability to fully extend the knee, with a rotational flexion/extension ‘trick’ required to regain full extension. Weakness, grinding, instability or giving way rarely result from meniscal pathology. On examination, there may be joint effusion, joint line tenderness, sensitive – specificity being 57–98% and 80–99%, and sensitivity being 10–66% and 16–58% respectively. 2,9 The most useful clinical test for meniscal injury is the Thessaly test, which is demonstrated in demonstrated a sensitivity of 90%, and specificity of 98% in detecting If clinically suspicious of meniscal injury, a trial of conservative measures may be considered or confirmation with magnetic resonance imaging (MRI). Unfortunately, general practitioners cannot currently order Medicare funded MRI, although this may change with The Royal Australian College of General Practitioners recent submission twisting injury to the knee. Tears present as severe pain, swelling, and pain (with medial pain generally being indicative of a medial tear and Partial meniscectomy (removal of the torn section) is one of the most In older patients, referral is appropriate if conservative management Magnetic resonance imaging is the gold standard, first choice for Sagittal peripheral meniscal images demonstrate the normal anatomical ‘bow-tie configuration’ (the central meniscal body with the anterior and posterior horns as well circumscribed triangles. On MRI, meniscal tears are evident as a linear signal intensity that extends for the orthopaedic surgeon to predict meniscal repairability, assisting informed discussion with patients and scheduling appropriate operating be seen on MRI, this does not mandate surgery. The absolute indication for specialist referral is the locked knee – loss of joint function necessitates surgical intervention. Referral is also indicated if the diagnosis is uncertain for review and to access MRI. Magnetic resonance imaging can also be effectively used to estimate fails to improve symptoms. As the risk of osteoarthritis is increased delamination occurs in degenerative injuries, while the fibrous appropriate to refer all young patients for opinion if symptoms do not rapidly improve. degeneration associated with ageing and tend to be horizontal tears. The difference in tear type between these populations is explained structure is ruptured in a vertical fashion in younger patients. Meniscal by the three-dimensional fibrous structure of the meniscus: horizontal tomography (CT) is markedly inferior to MRI for meniscal imaging. 12 investigation of suspected meniscal tears. 2,13–16 tear incidence may be as high as six per 1000 population 6 with a 2.5 to 4 times male predominance. Age of injury peaks at 20–29 years. 7 commonly performed orthopaedic surgical procedures. 8 through the meniscal substance to a free edge 17 ( Figure 4 ). Tears are typically vertical in young patients and horizontal in the elderly ( Figure 5 ). History and examination the vascular zone classification (see Treatment ) of tears. 18 This is useful theatre time. 18 It is essential to remember that just because a tear can Indications for specialist referral if meniscal structures are not optimally functional, 7 it may also be and the joint is held in a flexed position. 1 In late presentations, there may be significant quadriceps wasting. McMurray ( Figure 1 ) and Apley tests ( Figure 2 ) are often positive, although these are specific but not Figure 3 . Although rarely taught and poorly utilised, recent validation Figure 1. McMurray test: The patient lies supine on meniscal injury. 10 the bed with the hip and knee both flexed. With the foot as close to the hip as possible, the clinician Diagnosis holds the knee joint (with fingers along the joint line) with one hand, and the other hand rotates the tibia internally and externally while extending and flexing the knee. If the test is positive (suggesting a meniscal tear), the patient will feel pain and the clinician will feel and/or hear meniscal movement when the meniscus is compressed between the tibia and femur 32 to the Australian Government Department of Health and Ageing. 11 REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 41, NO. 4, APRIL 2012 183